SPOKANE COUNTY FIRE DISTRICT NO. 12
_____ Firefighter _____ EMS
NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
HOW LONG AT THIS ADDRESS:_______ TELEPHONE:__________________________
PERSONAL HISTORY
DATE OF BIRTH:_________ AGE:_____ MARITAL STATUS: ____SINGLE ____MARRIED
NAME OF SPOUSE:_____________________________________________________________
HEIGHT:_______ WEIGHT:_________ HAIR COLOR:___________ EYE COLOR:_______
SOCIAL SECURITY NUMBER:_______________________________
WASHINGTON STATE DRIVERS LICENSE #:______________________________________
RESTRICTIONS OR ENDORSEMENTS ON WSDL:__________________________________
TRAFFIC CITATIONS INLAST THREE YEARS:_____________________________________
FELONY CONVICTIONS:________________________________________________________
MEDICAL AND EMERGENCY:
IN CASE OF EMERGENCY NOTIFY:______________________________________________
RELATIONSHIP:______________________ ADDRESS/PHONE:________________________
PHYSICIAN:_____________________________________ PHONE:______________________
BLOOD TYPE:_______________ ALLERGIES:______________________________________
PHYSICAL RESTRICTIONS, DISABILITIES, OR LIMITATIONS (INCLUDE VISION, HEARING, BACK PROBLEMS, LIFTING ABILITY, FEAR OF HEIGHTS, ETC.)_____________________________________________________________________________
EDUCATION:
HIGH SCHOOL GRADUATE: ___ YES ___ NO ___ GED
COLLEGE (MARK HIGHEST YEAR COMPLETED): __0 __1 __2 __3 __4 __5 __6+
DEGREE __NONE __AA/AS __BA/BS __MASTER __OTHER (SPECIFY)________________
MAJOR AREAS OF STUDY______________________________________________________
EMPLOYMENT HISTORY:
PRESENT EMPLOYER:__________________________________________________________
ADDRESS:_________________________________________ PHONE:____________________
OCCUPATION:______________________________________ SHIFT:____________________
EMPLOYMENT DATE:_____________________________________
PREVIOUS EMPLOYER:________________________________________________________
ADDRESS:_________________________________________ PHONE____________________
OCCUPATION:____________________ EMPLOYMENT DATES:_______________________
FIREFIGHTER HISTORY:
Training:_____ None _____ Washington State Fundamentals of Firefighting
Other training (include dates, locations and certificates):_________________________________
______________________________________________________________________________
Experience: ____ None ____ Structural _____ Forest _____ Field _____other: list dates and locations:______________________________________________________________________
FIRST AID – EMS HISTORY:
Training:_____ None _____ Prior training – level:_____________ date expired:______________
PRESENT QUALIFICATIONS: _____basic first aid _____advanced first aid
_____first responder – expires:_____________
_____ EMT – state:________ expires:________
_____IV tech _____ Airway tech _____Defib
_____Paramedic – state: _____ expires:_____
_____RN _____ LPN ____________ other
EXPERIENCE:_____ none _____ field EMS (fire or ambulance) _____ ER _____ other, give date and location ________________________________________________________________
REFERENCES: (no relatives) list name, address, telephone number
1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
CERTIFICATION:
I hereby certify that the answers given in this application are true and correct to the best of my knowledge. Signature____________________________________________ Date:____________
Acceptance by District: ___________ accepted __________ not accepted
Fire Chief:_____________________________________________________ Date:___________
MEDICAL EXAMINATION QUESTIONEER
Are you in good health__________ do you have or previously had any disabilities whereby you full physical capacities are limited yes:_____ no:_____ if so explain:______________________
______________________________________________________________________________
Have you ever had any of the following diseases or conditions: (if so please explain)
Heart trouble:____________________________________________________________
Kidney or Urinary trouble:__________________________________________________
Tuberculosis or lung disease:________________________________________________
Stomach ulcers/gastrointestinal disease:________________________________________
Diabetes:________________________________________________________________
Epilepsy:________________________________________________________________
Mental disease:___________________________________________________________
Nervous system problems:__________________________________________________
Rheumatism/arthritis:______________________________________________________
Back problems:___________________________________________________________
Allergies (ie: asthma, hay fever, eczema):______________________________________
Vision defects:___________________________________________________________
Hearing defects:__________________________________________________________
Hernias:________________________________________________________________
What serious illnesses, accidents, injuries or operations have you had?______________________
______________________________________________________________________________
List any government, insurance compensations or disability awards you have received.
What for?______________________________________________________________________
______________________________________________________________________________
(I hereby certify that the above answers are full, complete and true to the best of my knowledge.)
Volunteer’s signature:______________________________________ Date:_________________
SPOKANE COUNTY FIRE DISTRICT NO. 12
PHYSICAL EXAMINATION
APPOINTMENT TIME AND DATE:_______________________________________________
TO BE FILLED OUT BY PHYSICIAN:
HEIGHT:_________ WEIGHT:_________ PULSE:_________ BLOOD PRESSURE:_________
GENERAL APPEARANCE:_______________________________________________________
VISION: UNCORRECTED: R_______ L_______ CORRECTED: R_______ L_______
NECK:________________________________________________________________________
LUNGS:_______________________________________________________________________
HEART:_______________________________________________________________________
ABDOMEN:___________________________________________________________________
INGUINAL REGION:____________________________________________________________
SPINE:________________________________________________________________________
EXTREMITIES: LIMITED MOTION OR IMPAIRED FUNCTION, DEFORMITIES:________
______________________________________________________________________________
NERVOUS SYSTEM: PUPILS:____________ KNEE JERKS:_____________
ROMBERG____________ TREMORS______________ GAIT_____________
PHYSICIAN’S OPINION:
CAPABLE OF SUSTAINED ARDUOUS DUTY:_______________________________
CAPABLE OF MODIFIED DUTY:__________________________________________
LIMITATIONS:__________________________________________________________
_______________________________________ __________________
PHYSICIAN’S SIGNATURE DATE
____________________________________________
VOLUNTEER’S SIGNATURE
____________________________________________
SIGNATURE OF FIRE CHIEF OR EMS DIRECTOR
SPOKANE COUNTY FIRE DISTRICT NO. 12
FIRE DISTRICT POLICY
REQUIREMENTS FOR PHYSICAL EXAM BY PHYSICIAN DATE:_______________
If a physical examination is required, the Fire Chief and/or EMS Director will inform the District Secretary who will then fill in the Procedure form, make the appointment with the Medical Director at which time the volunteer will take the form back to either the Fire Chief or the Ambulance Director before said appointment and have it signed. At the time of the appointment, the volunteer will have the Medical Director sign and return the form to the secretary.
COMMISSIONERS:
Gregg Wernz
Ron Tee
Tom Pottratz
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